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J Thorac Cardiovasc Surg 2003;125:96-100
© 2003 The American Association for Thoracic Surgery
General Thoracic Surgery (GTS) |
From the Department of General Thoracic Surgery, Osaka University, Graduate School of Medicine,a and the Division of Surgery, Toneyama National Hospital,b Osaka, Japan.
Received for publication Feb 12, 2002. Revisions requested March 11, 2002; revisions received April 3, 2002. Accepted for publication May 21, 2002. Address for reprints: Mitsunori Ohta, MD, Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, E1 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan (E-mail: ohta{at}surg1.med.osaka-u.ac.jp).
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsDiscussionReferences |
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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1-3 Various techniques involving vital tissues have been used to lessen the usually high incidence of postoperative complications among patients undergoing bronchial sleeve resection after induction therapy. 4-6 We have had some success with a telescoping anastomosis for primary sleeve resection without any anastomosis-related complications, so in 1993 we also began to use a telescoping method for bronchoplasty procedures after induction therapy. A recent study found that preoperative chemotherapy did not significantly affect morbidity or mortality after surgery, 7 and our experience with sleeve resections after induction therapy confirmed those results. We examined the influence of induction therapy on sleeve resection surgical results by retrospectively comparing patients who received induction therapy with those who did not. |
Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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Sixteen patients received cisplatin-based combination chemotherapy with concurrent radiation therapy to the primary tumor and mediastinum before the operation, and another 4 patients received only chemotherapy. Chemotherapy treatments consisted of four different combinations: cisplatin and vindesine were administered to 11 patients; cisplatin, vindesine, and mitomycin were administered to 4 patients; cisplatin and docetaxel were administered to 4 patients; and low-dose carboplatin as an enhancer of radiation was administered to 1 patient. All patients, except for 2 in the cisplatin and vindesine therapy group, received two cycles of chemotherapy. Radiation therapy with an average of 42 Gy (range 30-50 Gy) was initiated concurrently at 2 Gy/(fraction · d) on the first day of the initial cycle of chemotherapy. Patients receiving induction therapy underwent surgical resection of the residual tumor at the primary site and vestiges on neighboring organs within 4 weeks after the last treatment.
Sleeve lobectomy was achieved with an anteroaxillar thoracotomy in principle. When a radical pretracheal or paratracheal lymphadenectomy was required in a left-sided operation, a trapdoor thoracotomy (half median sternotomy with fourth intercostal space thoracotomy) was performed. A standard posterolateral thoracotomy was used for right sleeve pneumonectomy and a bilateral anteroaxillar thoracotomy was performed for left sleeve pneumonectomy to achieve adequate dissection of the mediastinal lymph nodes.
Operative procedure
Resection of the subcarinal, paratracheal, and hilar peribronchial lymph nodes was carried out before bronchial incision. For patients with a Pancoast tumor, a supraclavicular lymphadenectomy was also performed. The anastomosis was constructed of a single interrupted whole-layer suture with 4-0 PDS-II or Maxon sutures for sleeve lobectomy and 3-0 PDS-II (Ethicon, Inc, Somerville, NJ) or Maxon (United States Surgical Corp, Norwalk, Conn) sutures for sleeve pneumonectomy. After two sutures were placed around the cartilages at the mediastinal end, the first suture was tied in an extraluminal fashion. The subsequent suture was then placed before the second suture was knotted (Figure 1). The telescoping effect was achieved by placing the stitches around the proximal and distal cartilage. The anastomosis of the membranous portion was performed with either an interrupted or a continuous suture technique. When the anastomosis was complete, the bronchus was telescoped by a depth of one circumference of cartilage. Wrapping of the anastomosis was not performed; however, a pedicled pericardial fat pad was used for coverage of the vascular anastomosis in cases of combined vascular sleeve resection. The anastomosis was checked for leaks with a pressure of 30 cm H2O for 3 seconds.
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Fiberoptic bronchoscopic examinations after surgery
At the end of the operation, the anastomosis was inspected with a bronchoscope. Bronchoscopic examination was repeated 1 and 2 weeks later, or every week if postoperative complications or prolonged mucosal healing at the anastomotic site was observed.
Statistical analysis
Differences between two groups were tested for significance by the 
2 test for categoric variables and the Student t test for continuous variables. Survival was estimated by the Kaplan-Meier method.
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Results |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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).
Complications in patients who received induction therapy
A total of 7 patients who received induction therapy (35%) had postoperative complications (Table 2). Two patients with poor pulmonary function required mechanical ventilation with tracheotomy, and 1 patient acquired pneumonitis from methicillin-resistant Staphylococcus aureus and received medical treatment under mechanical ventilation. Further complications included 1 patient who underwent dissection of a right-sided Pancoast tumor and had recurrent nerve and ulnar nerve palsy develop, 2 patients who had pleural empyema develop, and 1 patient in whom stricture of the anastomosis, which developed after infection with Pseudomonas cepacia at the anastomosis site, was successfully treated with balloon dilatation after the infection had resolved. Bronchoscopic examination frequently revealed white, necrotic mucosa along the cartilage of the distal bronchial end, which persisted for approximately 3 weeks.
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). One patient required mechanical ventilation for 2 days after surgery because of laryngeal edema, 1 acquired pleural empyema, and 1 acquired chylothorax. The rates of morbidity were 35% (n = 7/20) among patients who received induction therapy and 11% (n = 3/28) among those who did not. An anastomosis-related complication was observed in 1 patient who received induction chemoradiotherapy. No postoperative deaths occurred, and all patients were discharged in an ambulatory condition.
Survival and cause of death
Patients were followed up from 4 to 93 months (mean ± SD 25.4 ± 19.6 months). For the analysis of survival, 3 patients with carcinoid lung cancer and 1 with adenoid-cystic carcinoma were excluded, because the prognoses for these types of lung cancer are much better than for other types of non-small cell lung cancer. Four patients who received induction therapy died between postoperative months 16 and 53. One of these had local recurrence in the mediastinum 13 months after the operation, 2 had tumor recurrence at a distant site, and 1 died of a non-tumor-related cause. Six who did not receive induction therapy died between postoperative months 5 and 32. One of these patients had local recurrence in the residual lung 30 months after surgery, 5 had tumor recurrence at a distant site, and 1 died of pneumonitis. The median survivals were 19.3 months for all 44 patients, 23 months for the 20 patients who received induction therapy, and 17.9 months for the 24 who did not receive induction therapy.
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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5,8 Rendina and colleagues 4 showed that a bronchoplasty with vascular reconstruction could reduce the rate of pneumonectomy to 7.3% and considered bronchovascular reconstructive surgery to be an effective alternative to a pneumonectomy after induction chemotherapy. In our series of patients, induction therapy was indicated for those with stages IIIA and IIIB disease. When the patients had a resectable T4 tumor, such as a carinal invasion without N2 or N3 disease, a primary operation was performed. Overall, we performed surgery on 86 patients after induction therapy, 20 (23%) of whom underwent sleeve resection. The choice of sleeve resection for patients after induction therapy was based on curative intent and the desire to preserve as much functional lung volume as possible. The 28 patients who did not receive induction therapy underwent operations with the same intent.
Induction therapy, particularly irradiation, may cause serious anastomotic complications. 9,10 According to several reports, radiotherapy before sleeve resection should be avoided 9,11 or limited to 30 Gy. 12 When sufficient irradiation dosages are used, the use of omentum to enhance the blood supply is recommended. 6 When preoperative chemotherapy is performed, bronchial sutures should be protected by well-vascularized tissue, such as an intercostal muscle flap. 4 In the patients in this retrospective study, wrapping to prevent early complications may have been unnecessary, as shown in a previous experimental report, 13 even for patients who received induction therapy. Moreover, a telescopic procedure without wrapping has frequently been applied to single-lung transplantation with good results. 14 We believe that for a successful telescope it is crucial to achieve a depth equal to one cartilage and to cover the full circumference of the bronchus. A telescoping anastomosis seems to be a simple and reliable technique, especially for patients receiving induction therapy.
The results from our series of 48 consecutive cases indicate that bronchoplasty can be performed fairly safely in patients undergoing induction therapy, including irradiation. Morbidity of patients undergoing airway reconstruction with wrapping of a vascularized tissue flap after induction chemotherapy has been reported to be 11% (n = 3/27), 4 and the rate increased to 36% (n = 8/22) when concomitant with radiotherapy. 6 Our postoperative morbidity rate of 35% among patients who received induction therapy lies within that range, and the rate of anastomotic stricture was only 5.0% (n = 1/20). Further, the morbidity rate among the 28 patients who underwent a sleeve resection without induction therapy was 11%, and no anastomosis-related complications were observed in that group.
Our patients had no local recurrences in the airway; however, 2 (4.2%) had intrathoracic relapses of disease and 7 had relapses at a distant site. The median survival was 23 months among patients with induction therapy and 18 months among those without it. Although it is not appropriate to compare median survivals between the patients who received induction therapy and those who did not because they had different stages of disease, the median survival findings for our patients who received induction therapy compared favorably with those in other major series. 2,5,8 Our study population was not large enough to detect small differences in surgical morbidity or survival, so the influence of induction therapy must be carefully evaluated. Nevertheless, the surgical outcomes relating to bronchial anastomosis were similar to the best results reported elsewhere. 4,12
In summary, the results of our retrospective study suggest that morbidity and mortality after sleeve resection were not significantly affected by preoperative induction therapy when a meticulous technique was used and proper patient selection was performed.
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